The Effect of FDM On Micrographia in Parkinsonism

The effect of the Fascial Distortion Model
on Micrographia in Parkinsonism -
a single system study

Andreas Philipp Kacsir
Kontaktinformationen:
Andreas Philipp Kacsir, dipl. PT BSc, MscPt, Msc Neurorehabilitationsforschung,
FDM-Therapeut (EFDMA), Fachdozent für Neurorehabilitation
Zentrum für Physiotherapie am Markt GmbH
Marktstrasse 4
9435 Heerbrugg
tel. + 41 71 722 81 81
fax. +41 71 722 81 82
mail. andreas.kacsir@physiotherapie-ammarkt.ch
web. www.physiotherapie-ammarkt.ch
Unterschrift:
1. Table of content
1. TABLE OF CONTENT............................................................................................. 2
2. ACKNOWLEDGEMENTS ....................................................................................... 7
3. ABSTRACT/KEY WORDS ...................................................................................... 8
4. INTRODUCTION ................................................................................................... 10
4.1 Epidemiology of the idiopathic Parkinson disease and the occurrence of micrographia .......................... 10
4.2 Therapy approaches ............................................................................................................................... 11
4.3 The Fascial Distortion Model (FDM) ........................................................................................................ 12
4.4 Aim of the study ..................................................................................................................................... 12
5. MATERIALS AND METHODS .............................................................................. 13
5.1 Patient .................................................................................................................................................... 13
5.2 Assessments ........................................................................................................................................... 14
5.2.1 Handwriting task ................................................................................................................................. 14
5.2.2 Signature ............................................................................................................................................. 14
5.2.3 Motor status ........................................................................................................................................ 15
5.3 Treatment method according to the Fascial Distortion Model (FDM) ...................................................... 15
5.3.1 Procedure of the treatment ................................................................................................................. 15
5.4 Statistical Evaluation .............................................................................................................................. 16
The effect of the Fascial Distortion Model on Micrographia in Parkinsonism – a single system study
2

6. RESULTS .............................................................................................................. 17
6.1 General characteristics ........................................................................................................................... 17
6.1.1 Handwriting samples ........................................................................................................................... 21
6.1.1.1 Handwriting sample 1a ..................................................................................................................... 21
6.1.1.2 Handwriting sample 1b ..................................................................................................................... 21
6.1.1.9 Handwriting sample 5a (Follow up) ................................................................................................... 23
6.2 Measurement 1a and b ........................................................................................................................... 23
6.6 Measurement 5 (Follow-‐up) ................................................................................................................... 25
6.7 Time for the handwriting task ................................................................................................................. 26
6.8 Mean letter height .................................................................................................................................. 26
6.9 Sentence length ...................................................................................................................................... 27

3

6.10 Surface area .......................................................................................................................................... 27
6.11 Signature .............................................................................................................................................. 28
7. DISCUSSION......................................................................................................... 29
7.1 Bottom-‐up-‐Theory: a new hypothesis of the genesis of idiopathic Parkinson’s disease ........................... 30
8. CONCLUSION ....................................................................................................... 33
8.1 Impact on clinical practice ...................................................................................................................... 33
8.2 Impact on future research ...................................................................................................................... 33
9. REFERENCES ...................................................................................................... 35
10. APPENDIX........................................................................................................... 39
10.1 Strength ............................................................................................................................................... 39
10.2 Range of motion ................................................................................................................................... 43
10.3 MDS-‐UPDRS items ................................................................................................................................ 46
10.3.1 Rigidity MDS-‐UPDRS item 3.3 ............................................................................................................. 46
10.3.2 Finger Tapping MDS-‐UPDRS item 3.4 ................................................................................................. 46
10.3.3 Pronation-‐supination movements of hands MDS-‐UPDRS item 3.6 ...................................................... 47
Table 5: Pronation-‐supination movements of hands MDS-‐UPDRS item 3.6 ................................................... 48
10.3.4 tremor MDS-‐UPDRS item 2.10 ........................................................................................................... 49
10.3.5 Kinetic tremor of the hands MDS-‐UPDRS item 3.16 ............................................................................ 49
10.3.6 Hoehn and Yahr stage ........................................................................................................................ 50

4

10.3.6 Letter of Content ............................................................................................................................... 51
Tables
Table 1: Baseline characteristics ....................................................................................... 18
Table 2: Motor status ........................................................................................................... 19
Table 3: Rigidity MDS-UPDRS item 3.3 ........................................................................... 46
Table 4: Finger Tapping MDS-UPDRS item 3.4 .............................................................. 47
Table 5: Pronation-supination movements of hands MDS-UPDRS item 3.6 .............. 48
Table 6: Tremor MDS-UPDRS item 2.10 ......................................................................... 49
Table 7: Kinetic tremor of the hands MDS-UPDRS item 3.16 ....................................... 50
Table 8: Hoehn and Yahr stage ......................................................................................... 50
Diagrams
Diagram 1: time .................................................................................................................... 26
Diagram 2: mean letter height ............................................................................................ 26
Diagram 3: sentence length ................................................................................................ 27
Diagram 4: surface area ...................................................................................................... 27
Diagram 5: signature ........................................................................................................... 28
Diagram 6: strength hand flexion ....................................................................................... 39
Diagram 7: strength hand extension ................................................................................. 39
Diagram 8: strength supination .......................................................................................... 40
Diagram 9: strength pronation ............................................................................................ 40
Diagram 10: strength elbow flexion ................................................................................... 41
Diagram 11: strength elbow extension .............................................................................. 41
Diagram 12: hand-dynamometer ....................................................................................... 41

5

Diagram 13: pinch-dynamometer ...................................................................................... 42
Diagram 14: ROM hand flexion .......................................................................................... 43
Diagram 15: ROM hand extension .................................................................................... 43
Diagram 16: ROM supination ............................................................................................. 44
Diagram 17: ROM pronation ............................................................................................... 44
Diagram 18: ROM elbow flexion ........................................................................................ 45
Diagram 19: ROM elbow extension ................................................................................... 45
6

2. Acknowledgements
I would like to express my special appreciation to the team at the Zentrum für Physio-
therapie am Markt GmbH, you have been a tremendous help to me. I would like to
thank you for encouraging my research.
I would also like to thank many members of the European Fascial Distortion Associa-
tion. Your advice on both research, as well as on my career, have been invaluable.
A special thanks to my family. Words cannot express how grateful I am.
Finally, I would also like to thank to my beloved wife, Linda Kacsir and my brother,
Dr. med. Bela Kacsir. Thank you both for supporting me in everything.
7

3. Abstract/Key words
Introduction
Patients with idiopathic Parkinson’s disease typically suffer from a wide range of mo-
tor and non-motor problems. Besides the cardinal symptoms of akinesia, tremor and
rigidity, micrographia, another common symptom in Parkinson’s disease, is charac-
terized by small handwriting with further progressive reduction in size. There is no
proven theory that could explain the pathophysiology of micrographia exactly. The
therapies described so far are time-consuming and involve a high risk of relapse. Un-
til now, there exists no specific manual treatment for improving micrographia in neu-
rorehabilitation.
Methodology
The method according to the fascial distortion model addresses local changes in the
area of the forearm fascia. It is suited to reduce functional impairments associated
with this symptom complex by applying targeted manual techniques.
Main Outcome Measures
One patient (male) participated in the study. A writing sample was used for the quan-
tification of the writing skills. Subsequently four treatments of the forearm fascia were
performed (once a week in four weeks). A follow-up measurement of four weeks was
taken.
8

Results
Evident improvements of writing speed, letter height and surface area were achieved.
Surprisingly, rigidity and diadochokinesia were improved as well. The long-term
measurement showed no deterioration of the effects.
Discussion
The fascial distortion model is a potential effective and low-priced method for influ-
encing writing skills in patients with idiopathic Parkinson’s Disease. In order to
change also neurological parameters, the treatment acts as a bottom-up therapy and
changes even neurological pathways and the perspective of understanding the dis-
ease.
Conclusion
FDM probably fills in a current gap in neurorehabilitation. Therefore, more research
on FDM is necessary in order to make reliable conclusions on its efficiency in long-
term rehabilitation. Larger randomized studies are needed to confirm these results.
Keywords: Parkinson’s Disease, Fascial Distortion Model, Micrographia and Hand-
writing
9

4. Introduction
4.1 Epidemiology of the idiopathic Parkinson disease (iPD) and the occurrence
of micrographia
Idiopathic Parkinson’s disease (iPD) is the second most common neurodegenerative
disease after Alzheimer’s disease, its prevalence reaching 1% of individuals over 60
years old [1]. Worldwide, there are approximately 4.1 million patients. According to
studies, the number will increase to around 8.7 million by the year 2030th. More than
15’000 patients live in Switzerland [2].
Patients with idiopathic Parkinson’s disease (iPD) typically suffer from a wide range
of motor and non-motor problems [3]. Besides the cardinal symptoms of bradykinesia
(slowness of movement), tremor and rigidity (muscular stiffness throughout the range
of passive movement in a limb segment) and postural and gait impairment, mi-
crographia, another common symptom in Parkinson’s disease, is characterized by
small handwriting with further progressive reduction in size [4]; [5]. Micrographia has
a high association with accurate diagnosis of Parkinson’s disease [6]; [7]. Moreover,
this problem can occur early in the disease and is one of the first symptoms ([4]; [8];
[9]); thus, it may be useful for early diagnosis of Parkinson’s disease ([5]; [10]). Par-
kinsonian handwriting is often characterized by lack of fluency, slowness, and less
frequently by micrographia.
The neurophysiological mechanisms underlying micrographia in iPD remain unknown
[11]. It has been suggested that micrographia is a component of bradykinesia, as
these two symptoms are correlated [5]. Inappropriate scaling of the dynamic muscle
force to the movement parameters, which has been proposed to contribute to brady-
kinesia [12], may be a reason for micrographia ([13]; [5]). However, the relationship
between micrographia and bradykinesia remains controversial [4]. It is well known
10

that micrographia can present at an early stage of Parkinson’s disease, even without
significant bradykinesia [11].
A cross-sectional study with 68 iPD-patients identified micrographia in 63.2% of the
cohort [5]. In a study of Ponsen et al. participants wrote a complete sentence and the
authors showed that letter height decreased in iPD-patients as writing progressed [9].
Handwriting is an important skill in all daily life. Any clinical condition that affects this
will have a significant impact on the patient. When patients present with an initial
complaint of micrographia, studies have shown that this symptom significantly in-
creases the likelihood of having PD (with positive likelihood ratios of 3-6) [14].
Micrographia usually manifests in two forms: ‘consistent’ and ‘progressive’. Con-
sistent micrographia is a total reduction in writing size compared with writing before
the development of the disease, whereas progressive micrographia is a gradual re-
duction in size during writing [15]. Most patients with micrographia exhibit both con-
sistent and progressive micrographia [11].
4.2 Therapy approaches
Micrographia is likely a manifestation of hypokinesia (smallness of movement), and
can be alleviated by levodopa [4] or high-frequency stimulation of the subthalamic
nucleus [16]. Levodopa also improves kinematics of handwriting, such as velocity,
acceleration, and stroke duration [17]; [18]. It has been commonly observed that ex-
ternal visual, auditory or verbal cues or attention can effectively increase the ampli-
tude of handwriting in iPD-patients with consistent micrographia ([19]; [20]; [21]; [22]).
Until now, there exists no specific manual treatment for improving micrographia in
iPD-patients.
11

4.3 The Fascial Distortion Model (FDM)
The fascial distortion model (FDM) is an anatomical perspective in which the underly-
ing etiology of virtually every musculoskeletal injury (and many neurological and
medical conditions as well) is considered to be comprised of one or more of six spe-
cific pathological alterations to of the body’s connecting tissues (fascial bands, liga-
ments, tendons, retinacula, etc.). In the manipulative practice of the FDM (known as
Typaldos manual therapy, or TMT), each injury is envisioned through the model and
the subjective complaints, body language, mechanism of injury, and objective find-
ings are woven together to create a meaningful diagnosis that has practical applica-
tions. These diagnoses describe the conception of how the fasciae are twisted in a
specific body segment where they cause specific problems [23].
4.4 Aim of the study
The aim of the case study was to
i. evaluate the effect of FDM on micrographia in idiopathic Parkinson’s Disease
ii. analyze long-time effects of FDM on micrographia in patients with idiopathic
Parkinson’s disease and
iii. determine if other motor dysfunctions (motor status, range of motion, bradyki-
nesia, rigidity, diadochokinesia) could be influenced by FDM.
12

5. Materials and Methods
5.1 Patient
One Patient with a diagnosed idiopathic Parkinson’s Disease (Hoehn & Yahr scale I-
III) was researched for the study. Handwriting problems, reflected by a score of 1 or
more on the handwriting item (2.7) of the Movement Disorder Society-sponsored re-
vision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) part II; Gen-
eral clinical characteristics of the patient such as gender, age, height, weight, disease
duration and most affected side and levodopa equivalent dose (LED, mg/24h) were
assessed. Specific in- and exclusion criteria are listed below.
Inclusion criteria consisted of:
i. a diagnosis of PD according to the United Kingdom PD Society Brain Bank cri-
teria;
ii. Hoehn and Yahr (H&Y) stage I to III in the on-phase of the medication cycle;
and
iii. Mini-Mental State Examination (MMSE) >24.
Exclusion criteria were:
i. upper limb medical problems (peripheral neuropathy) which would impede
handwriting;
ii. subjects with possibility of atypical parkinsonism, stroke, neuropathy in hands,
significant tremors, dystonia- and levodopa-induced dyskinesias;
iii. a history of depression or neurological diseases other than iPD and
iv. deep brain stimulation.
13

After complete explanation of the study protocol, written informed consent was ob-
tained from the patient prior to participation in the experiment. The medication intake
was stable (and no medication change was allowed during the study) and the as-
sessments were always tested at the same time in case of medication fluctuation.
5.2 Assessments
5.2.1 Handwriting task
The quantification of micrographia was assessed with a handwriting tasks. The sub-
ject was asked to write the sentences ‘‘Wegen meiner Parkinson-Erkrankung nehme
ich regelmässig bestimmte Medikamente ein. Es soll nun untersucht werden, ob sich
meine Handschrift in Zusammenhang mit der FDM-Therapie verändert’’ at a self de-
termined comfortable size and speed. The same sentence had to be written before
and after TMT treatment. Variables included sentence length (cm) (defined as the
vector between the beginning and end of both sentences), mean letter height (cm)
(defined as the vector between the most upper part and lower part of the six capital
letters ‘W, P, M, E, H, F’ and the writing speed of both sentences assessed by the
time per repetition (sec). Surface area (cm2) of the words Parkinson-Erkrankung,
Medikamente and Handschrift was calculated by framing the words within a quadri-
lateral with horizontal and vertical lines parallel to the sides of the sheet. The hand-
writing tasks were analyzed to evaluate the speed of movement to assess bradykine-
sia and the size of writing to assess micrographia.
5.2.2 Signature
Surface area of the signature (cm2) was calculated by framing the signature within a
quadrilateral with horizontal and vertical lines parallel to the sides of the sheet.
14

5.2.3 Motor status
The author assessed the motor status of the included patient. All the assessments
were assessed at baseline, two, three, four and eight weeks. All assessments were
taken in a quiet room at the Zentrum für Physiotherapie am Markt GmbH, Heerbrugg,
Switzerland, while sitting at a table on a height-adjustable chair. The patient was not
allowed to train writing skills at any time during the study. Strength of hand- and el-
bow muscles were assessed by the terms of the medical research council (MRC) and
a hand-dynamometer and a pinch-dynamometer. Range of motion was evaluated by
the neutral-0-method. Rigidity, finger-tapping, pronation-supination movements of
hands, tremor and kinetic tremor of the hands were assessed by using MDS-UPDRS
items. All assessments were taken before and after each treatment, altogether nine
assessments were evaluated.
5.3 Treatment method according to the Fascial Distortion Model (FDM)
The patient was asked to indicate the location of dysfunction in the upper extremity
while writing. The diagnosis was derived from the body language (BL) and the de-
scription of the patient, using FDM according to Typaldos [24]. The patient was treat-
ed once a week. Each treatment lasted maximally 20 minutes. Altogether, the patient
was treated four times.
5.3.1 Procedure of the treatment
Each intervention included the following handlings:
- Unfolding and refolding manipulations of interosseous membrane, and folding
manipulation of intermuscular septum
- Intermuscular septal folding distortions
- Tectonic technique (modified frogleg and reverse frogleg)

15

- Triggerbands of forearm
- Cylinder distortions of antebrachial fascia, hand and fingertips.
5.4 Statistical Evaluation
Descriptive statistics were used to show the characteristics of the sample. A linear
trend line was used to analyze the data. The trend line is an optimized straight line
that is used for simple linear data sets. The statistical description included the deter-
mination of maximum, minimum and mean value’s in cm. Data were analyzed using
Microsoft® Excel® for Mac 2011, Version 14.6.4.
16

6. Results
6.1 General characteristics
One patient (male) with a diagnosed idiopathic Parkinson’s Disease (Hoehn & Yahr
scale II) participated in the study. The patient was a retired caretaker in St. Gallen,
Switzerland. The patient was 67 years old, weighed 81kg, and was 1.87m tall. More
specific baseline characteristics are listed below in table 1. The average duration of
the four treatments was 19.20 minutes. No side effects were recorded. The partici-
pant completed all of the writing tasks. All evaluations were performed during the ‘On’
motor condition.
17

Table 1: Baseline characteristics
General data
Gender male
Age (y) 67
Height (m) 1.87
Weight (kg) 81
Dominant hand right
Disease duration (y) 8
Most affected side right
MMSE (0-30) 26
H&Y (0-5) 2
LED (mg/24h) Sifrol 1,75 mg
Symmetrel 200 mg
Madopar 5 mg
Madopar DR 125 mg
Abbreviations: H&Y = Hoehn and Yahr stage; h = hours; kg = kilogram; LED =
levodopa equivalent dose; mg = milligram; MMSE = Mini Mental State Examination;
y = years;
18

Table 2: Motor status
Motor status (only right side) 1a 1b 2a 2b 3a 3b 4a 4b FU Mean
Strength (MRC) 0-5
Hand flexion 4 4 4 5 5 5 5 5 5 4.7
Hand extension 4 4 4 4 4 4 5 5 5 4.3
Supination 4 4 4 5 5 5 5 5 5 4.7
Pronation 4 4 4 5 5 5 5 5 5 4.7
Elbow flexion 4 5 5 5 5 5 5 5 5 4.9
Elbow extension 4 4 5 5 5 5 5 5 5 4.8
Hand-Dynamometer (kg) 35 35 37 38 36 32 40 36.5 40 36.6
Pinch-Dynamometer (kg) 8 9.5 8 8.5 7.5 9.5 8.5 7.5 9 8.4
Range of motion (Neutral-0 Method)
Hand flexion 60 63 75 73 76 74 78 80 85 73.8
Hand extension 88 90 89 88 90 91 87 94 96 90.3
Supination 79 82 84 84 83 82 85 86 91 84.0
Pronation 91 90 91 92 93 90 89 92 94 91.3
Elbow flexion 139 140 134 137 133 135 135 137 140 136.7
Hand writing tasks
Time (sec): 373 292 288 248 301 280 279 263 251 286.1
Mean letter height (cm): 0.5 0.53 0.57 0.65 0.57 0.7 0.6 0.68 0.62 0.6
Sentence length (cm): 38.5 37.3 48.7 48.6 38.2 48.9 48.5 49.7 53.4 45.8
Surface area (cm2) 7.17 6.51 10.3 10.7 7.11 12.53 11.19 12.33 12.65 10.1
Signature (cm2) 2.1 1.12 1.05 1.8 1.2 1.62 1.19 1.62 1.33 1.4
Items from MDS-UPDRS-III
Rigidity (0-4) 3 3 2 2 2 3 2 1 1 2.1
Finger Tapping (0-4) 3 2 2 2 3 2 2 1 1 2.0
Pronation-supination movements of hands (0-4) 3 3 2 2 3 2 2 1 1 2.1
Tremor (0-4) 1 1 1 1 1 1 0 0 0 0.7
Kinetic tremor of the hands (0-4) 2 1 1 0 0 0 0 0 0 0.4

Abbreviations: cm2 = square centimeter; FU = follow-up; kg = kilogram; MDS-UPDRS-III = Movement Disorders Unified Parkinson’s
disease rating scale part 3; mm = millimeters; MRC = Medical Research Council; sec = seconds;
20

6.1.1 Handwriting samples (surface area of signature is not shown because of
patients privacy). More detailed descriptions are listed in chapter 6.2.
There is an objective change in the handwriting samples 1a to 5a. The writings were
initially reduced, slowed down, angle instead of garlands and arcades, slight trem-
bling, reduced bonding degrees and irregularities. After the treatment with TMT the
writing speed became faster, and looked firm and round.
6.1.1.1 Handwriting sample 1a
Picture 1: handwriting sample 1a
6.1.1.2 Handwriting sample 1b
Picture 2: handwriting sample 1b
21

22

6.1.1.9 Handwriting sample 5a (Follow up)
6.2 Measurement 1a and b
Strength (MRC) changed only in elbow flexion (4/5) and pinch-Dynamometer (8/9.5
kg). Only small change in range of motion was observed. The time for the writing task
decreased from 373 to 292 sec. Mean letter height increased from 0.50 to 0.53 cm.
Sentence length decreased from 38.5 to 37.3 cm. The surface area decreased from
7.17 to 6.51 cm2. Signature area decreased from 2.1 to 1.12 cm2. Rigidity (3/3), pro-
nation-supination movements of hands (3/3), tremor (1/1) showed no changes. Fin-
ger Tapping (3/2) and kinetic tremor of the hands (2/1) improved.
Strength (MRC) increased in hand flexion (4/5), supination (4/5), pronation (4/5),
hand-dynamometer (37/38kg) and pinch-dynamometer (8/8.5kg). Only small change
in range of motion was observed. Time for the writing task improved from 288 to 248
sec. Mean letter height increased from 0.57 to 0.65 cm. The sentence length de-
23

creased slightly from 48.7 to 48.6 cm. Surface area increased from 10.3 cm2 to 10.7
cm2. Signature area increased from 1.05 to 1.8 cm2. Rigidity (2/2), finger tapping
(2/2), pronation-supination movements of hands (2/2) and tremor (1/1) were stable.
Kinetic tremor of the hands (1/0) was improved.
The strength of the patient (MRC) decreased from 36 to 32 kg measured by the
hand-dynamometer and increased from 7.5 to 9.5 kg, measured by the pinch-
dynamometer. Only small improvement in range of motion was observed. The time
for the writing task decreased from 301 sec to 280 sec. Mean letter height increased
from 0.57 to 0.7 cm. Sentence length decreased from 38.2 to 48.9 cm. Surface area
increased from 7.17 to 12.53 cm2. Signature area increased from 1.2 to 1.62 cm2.
Rigidity increased (2/3), pronation-supination movements of hands (3/2) and finger
tapping (3/2) decreased, tremor (1/1) and kinetic tremor of hands (0/0) showed no
changes.
The strength of the patient (MRC) measured by the hand-dynamometer decreased
from 40 to 36.5 and 8.5 to 7.5 kg, measured by the pinch-dynamometer. Only small
changes in range of motion were observed. The time for the writing task decreased
from 279 sec to 263 sec. Mean letter height increased from 0.6 to 0.68 cm. Sentence
length decreased from 48.5 to 49.7 cm. Median surface area increased from 11.19 to
12.33 cm2. Signature area increased from 1.19 to 1.62 cm2. Only rigidity (2/1), finger
tapping (2/1) and pronation-supination movements of hands (2/1) decreased.
24

6.6 Measurement 5 (Follow-up)
The results of measurement 5 were compared to the last measurement 4b to evalu-
ate long-term effects. The strength of the patient (MRC) measured by the hand-
dynamometer increased from measurement 4b from 36.5 to 40 kg, respectively from
7.5 to 9 kg (pinch-dynamometer). Only slight improvements were seen in the range
of motion. The time for the writing task decreased from 263 to 251 sec. Mean letter
height decreased from 0.68 to 0.62 cm2. Sentence length improved from 49.7 to 53.4
cm. Surface area increased from 12.33 to 12.65 cm2. Signature decreased from 1.62
to 1.33 cm2. All items from the MDS-UPDRS-III remained stable.
25

6.7 Time for the handwriting task
The time for the writing task decreased steadily from M1a to M5 (FU) (R2 = 0.66).
After each treatment, the speed increased (M1b-M4b), but there was no linear corre-
lation (R2 = 0.14).
time for the handwritimg task

420
370
time (sec)
R² = 0.66 a
320
b
270 Linear (a)
R² = 0.14
Linear (b)
220
1 2 3 4 5
measurements
Diagram 1: time
6.8 Mean letter height
Mean letter height was always bigger after each treatment (M1b to M4b), R2 = 0.72).
In general, patients’ letter height increased steadily from M1a up until the follow-up
(R2 = 0.88).
mean letter height

0.8
0.75 R² = 0.72
letter height (cm)
0.7
0.65 a
0.6
0.55 b
0.5 R² = 0.88
Linear (a)
0.45
Linear (b)
0.4
1 2 3 4 5
measurements
Diagram 2: mean letter height

26

6.9 Sentence length
After M2, sentence length was longer after each treatment (R2 = 0.67). A small
elongation of the sentences can be seen in M1a to M5 (R2 = 0.48).
sentence length
60
sentence length (cm)
R² = 0.67
55
50
a
45 R² = 0.47635
b
40
Linear (a)
35
Linear (b)
30
1 2 3 4 5
measurements
Diagram 3: sentence length
6.10 Surface area
Surface area increased after each treatment (R2 = 0.79). In general, a small but non-
linear (r2 = 0.29) increase in size is shown.
surface area
17
surface area (cm2)
15
R² = 0.79412
13
a
11
b
9 R² = 0.2937
Linear (a)
7
Linear (b)
5
1 2 3 4 5
measurements
Diagram 4: surface area
27

6.11 Signature
Signature was bigger after each treatment (M2b to M4b, R2 = 0.34). M1a to M5
showed a small correlation (R2 = 0.48) in the increase of the size.
signature (cm2)
2.5
surface area (cm2)
2 R² = 0.34
a
1.5
b
1 R² = 0.48 Linear (a)
0.5 Linear (b)

1 2 3 4 5
measurements
Diagram 5: signature
In reason of of small evident changes and better readability the data of strength and
range of motion are shown in the appendix. See 10.1 for strength, diagram 1-13 and
see 10.2 range of motion, diagram 14-19. Further details about MDS-UPDRS items
are shown in 10.3, MDS-UPDRS-items, table 3-7 and Hoehn & Yahr scale is shown
in 10.3.6, table 8.
28

7. Discussion
The aim of the current pilot case study was to investigate the effects of FDM in mi-
crographia in idiopathic Parkinson’s disease. In this study, FDM was associated with
an improvement in most of the graphological variables assessed. These changes
were evident for handwriting tasks (time per repetition, mean letter height, sentence
length, surface area and signature). Writing size was examined to find objective
measures for micrographia. Surprisingly, all of the items from MDS-UPDRS-III (rigidi-
ty, finger tapping, pronation-supination movements of hands, tremor and kinetic
tremor of the hands) improved in short-term and long-term measurements.
In our sample the writings were initially reduced, slowed down, angle instead of gar-
lands and arcades, slight trembling, reduced bonding degrees and irregularities. After
the first treatment with TMT the writing speed became faster, and looked firm and
round. These results showed, that TMT is a fast and effective treatment to improve
micrographia and change motor dysfunctions caused by iPD. Furthermore, this is a
pilot study where long-term follow-up was recorded and the results showed im-
provements even without intervention. Moreover the method is very stressful for the
patient, any side effects were recorded.
One of the limitations of this study was the small sample size, which limits the num-
ber of statistically significant results and the generalization. A direct comparison with
alternative treatments was impossible because of the chosen study design. This
study has some further limitations. First, we measured only sentence length and let-
ter height and surface areas. Other writing kinematics such as amplitude of maximum
velocity and the number of movement units should be examined in future research to
provide information on the force and smoothness of handwriting. Second, we had the
paper aligned horizontally and vertically and maybe helped the patient’s orientation.
29

Third, although the patient was always tested at the same time, patient’s medication
intake was not always exactly and could interfere with the patient’s performance.
Fourth, however, the clinical tests from the items of MDS-UPDRS-III were difficult to
assess. The rigidity, as an example, is a symptom, which is very hard to quantify,
because it refers to an increased muscle tone noticed during subjective assessment
by a physician during passive movements of, for example, an affected arm. Fifth, this
study was not blinded. The author of this study treated the patient and evaluated the
data. And last, the reproduction of the manual treatment is very difficult. There is no
advice for measuring treatment pressure and forces onto the fascial tissues.
7.1 Bottom-up-Theory: a new hypothesis of the genesis of idiopathic
Parkinson’s disease
Until now, the pathophysiology of iPD remains unclear. This pilot case study sheds
some light onto a new hypothesis of the genesis of iPD. Different findings demon-
strated that consistent micrographia is related to dysfunction of the basal ganglia mo-
tor circuit; while a combination of dysfunction of the basal ganglia motor circuit and
disconnection of the pre Supplementary motor area (pre-SMA), rostral cingulate mo-
tor area (rCMA) and cerebellum is associated with progressive micrographia. In the
study of Wu et al. writing in iPD was associated with activations in the left primary
motor area, left pre-SMA and caudal SMA, right rCMA, bilateral premotor cortex
(PMC), left ventral PMC, right superior parietal lobule (SPL), bilateral inferior parietal
lobule (IPL), left putamen, left thalamus, left fusiform gyrus and bilateral cerebellum
[11].
Handwriting is a well-habituated, coordinated motor skill which has been exercised
for many years. Although writing can be considered a visually controlled motor task, it
30

also consists of highly automatically performed features, including writing size and
consistency [25]. In the study of Wu et al. writing in iPD was associated with activa-
tions in the left primary motor area, left pre-SMA and caudal SMA, right rCMA, bilat-
eral PMC, left ventral PMC, right superior parietal lobule (SPL), bilateral inferior pa-
rietal lobule (IPL), left putamen, left thalamus, left fusiform gyrus and bilateral cere-
bellum. These mechanisms are described as a top-down-theory. On the basis of ag-
ing and former distortions, the ability of the radio-ulnar interosseous membrane to
unfold and refold decreases, not affecting patient’s ADL and remains unobserved.
Due to this lack of movement, signals to the brain weaken. Therefore, cells in the
substantia nigra shrink slowly because of the principle of „use it or lose it“. This slight
alteration is clinically not relevant until approx. 80% of the cells of the substantia
nigra have perished and clinical symptoms such as bradykinesia and rigidity emerge.
These mechanisms could be described as a bottom-up-theory. Stephen Typaldos
wrote in his book that from the FDM perspective supination and pronation of the
forearm are to a large extent made possible by the ability of the radio-ulnar interos-
seous membrane to unfold and refold. In the FDM, muscle movement of any kind
(even spasm, tremor, or hypertonia) is considered to be triggered by signals from the
brain commanding that muscle to move. And since fascia acts as a mechanical sen-
sory system, cylinder distortions cause an uneven pull of the coils which is registered
in the nervous system as unequal tension. The uneven mechanical pull varies each
instance of muscle contraction since the coils rotate with contraction, pronation or
supination. This sends constant but geographically changing inequalities of mechani-
cal tension sensory input to the brain from very closely adjacent areas [23]. So far
there is no cure, because the root cause of the dying off of the nerve cells is un-
known, despite intensive research.
31

Conflict of interest
No potential conflict of interest relevant to this article was reported.
32

8. Conclusion
8.1 Impact on clinical practice
The results of this clinical study show that the treatment method according to the fas-
cial distortion model is a low-priced, rapid and effective option to ameliorate writing
performance and even motor symptoms (rigidity and bradykinesia) in a patient with
iPD. Until now, there exists no specific manual treatment for improving micrographia
in iPD-patients. Therefore, we suggest that FDM may be helpful in improving hand-
writing difficulties among iPD patients. Due to the fact that the genesis of iPD still re-
mains unclear, this new approach can lead to a better understanding of the patholog-
ical process and change the point of view. If larger randomized studies confirm these
results, FDM should be included in the multidisciplinary approach necessary for iPD
management.
8.2 Impact on future research
In line with this approach, we also suggested that computerized analysis of handwrit-
ing movements represents a simple, noninvasive and useful tool that can contribute
to both iPD diagnosis and follow-up for clinicians who deal with iPD micrographia.
Taken together, these findings turn iPD micrographia into a reliable physiological bi-
omarker for the early detection of iPD. Future research with a larger sample size will
be important for detecting potential differences that may provide alternative explana-
tions for the effect of FDM and handwriting observed in this study. To improve meth-
odological quality, the study should be triple blinded, this means that one researcher
33

should treat the patient’s forearm with TMT, another should extract the data from the
handwriting tasks and the third researcher should evaluate the gathered data.
34

9. References
[1] R. L. Nussbaum and C. E. Ellis, "Alzheimer's disease and Parkinson's
disease," N Engl J Med, vol. 348, pp. 1356-64, Apr 3 2003.
[2] P. Schweiz, "Epidemiologie von Parkisnon," ed, 2016.
[3] E. Heremans, E. Nackaerts, G. Vervoort, S. Broeder, S. P. Swinnen, and
A. Nieuwboer, "Impaired Retention of Motor Learning of Writing Skills in
Patients with Parkinson's Disease with Freezing of Gait," PLoS One, vol.
11, p. e0148933, 2016.
[4] J. E. McLennan, K. Nakano, H. R. Tyler, and R. S. Schwab, "Micrographia
in Parkinson's disease," J Neurol Sci, vol. 15, pp. 141-52, Feb 1972.
[5] A. Wagle Shukla, S. Ounpraseuth, M. S. Okun, V. Gray, J. Schwankhaus,
and W. S. Metzer, "Micrographia and related deficits in Parkinson's
disease: a cross-sectional study," BMJ Open, vol. 2, 2012.
[6] W. J. Mutch, W. C. Smith, and R. F. Scott, "A screening and alerting
questionnaire for parkinsonism," Neuroepidemiology, vol. 10, pp. 150-6,
1991.
[7] J. Duarte, L. E. Claveria, J. de Pedro-Cuesta, A. P. Sempere, F. Coria, and
D. B. Calne, "Screening Parkinson's disease: a validated questionnaire
of high specificity and sensitivity," Mov Disord, vol. 10, pp. 643-9, Sep
1995.
35

[8] G. Becker, A. Muller, S. Braune, T. Buttner, R. Benecke, W. Greulich, et
al., "Early diagnosis of Parkinson's disease," J Neurol, vol. 249 Suppl 3,
pp. III/40-8, Oct 2002.
[9] M. M. Ponsen, A. Daffertshofer, E. Wolters, P. J. Beek, and H. W.
Berendse, "Impairment of complex upper limb motor function in de novo
Parkinson's disease," Parkinsonism Relat Disord, vol. 14, pp. 199-204,
2008.
[10] S. Rosenblum, M. Samuel, S. Zlotnik, I. Erikh, and I. Schlesinger,
"Handwriting as an objective tool for Parkinson’s disease diagnosis," J
Neurol, vol. 260, pp. 2357-61, 2013.
[11] T. Wu, J. Zhang, M. Hallett, T. Feng, Y. Hou, and P. Chan, "Neural
correlates underlying micrographia in Parkinson's disease," Brain, vol.
139, pp. 144-60, Jan 2016.
[12] A. Berardelli, J. P. Dick, J. C. Rothwell, B. L. Day, and C. D. Marsden,
"Scaling of the size of the first agonist EMG burst during rapid wrist
movements in patients with Parkinson's disease," J Neurol Neurosurg
Psychiatry, vol. 49, pp. 1273-9, Nov 1986.
[13] A. W. Van Gemmert, H. L. Teulings, J. L. Contreras-Vidal, and G. E.
Stelmach, "Parkinson's disease and the control of size and speed in
handwriting," Neuropsychologia, vol. 37, pp. 685-94, Jun 1999.
36

[14] V. M. L. Kompoliti K., The encyclopedia of movement disorders vol. 1:
Elsevier, 2010.
[15] E. J. Kim, B. H. Lee, K. C. Park, W. Y. Lee, and D. L. Na, "Micrographia on
free writing versus copying tasks in idiopathic Parkinson's disease,"
Parkinsonism Relat Disord, vol. 11, pp. 57-63, Jan 2005.
[16] H. R. Siebner, A. Ceballos-Baumann, H. Standhardt, C. Auer, B. Conrad,
and F. Alesch, "Changes in handwriting resulting from bilateral high-
frequency stimulation of the subthalamic nucleus in Parkinson's
disease," Mov Disord, vol. 14, pp. 964-71, Nov 1999.
[17] K. W. Lange, L. Mecklinger, S. Walitza, G. Becker, M. Gerlach, M.
Naumann, et al., "Brain dopamine and kinematics of graphomotor
functions," Hum Mov Sci, vol. 25, pp. 492-509, Oct 2006.
[18] O. Tucha, L. Mecklinger, J. Thome, A. Reiter, G. L. Alders, H. Sartor, et
al., "Kinematic analysis of dopaminergic effects on skilled handwriting
movements in Parkinson's disease," J Neural Transm (Vienna), vol. 113,
pp. 609-23, May 2006.
[19] S. P. Swinnen, M. Steyvers, L. Van Den Bergh, and G. E. Stelmach,
"Motor learning and Parkinson's disease: refinement of within-limb and
between-limb coordination as a result of practice," Behav Brain Res, vol.
111, pp. 45-59, Jun 15 2000.
37

[20] A. Nieuwboer, S. Vercruysse, P. Feys, O. Levin, J. Spildooren, and S.
Swinnen, "Upper limb movement interruptions are correlated to freezing
of gait in Parkinson's disease," Eur J Neurosci, vol. 29, pp. 1422-30, Apr
2009.
[21] M. S. Bryant, D. H. Rintala, E. C. Lai, and E. J. Protas, "An investigation
of two interventions for micrographia in individuals with Parkinson's
disease," Clin Rehabil, vol. 24, pp. 1021-6, Nov 2010.
[22] S. D. Ringenbach, A. W. van Gemmert, H. A. Shill, and G. E. Stelmach,
"Auditory instructional cues benefit unimanual and bimanual drawing in
Parkinson's disease patients," Hum Mov Sci, vol. 30, pp. 770-82, Aug
2011.
[23] S. Typaldos, Clinical and Theoretical Application of the Fascial
Distortion Model Within the Practice of Medicine and Surgery, 4th ed.
ed.: Typaldos Publishing Co, 2002.
[24] EFDMA, "Das Fasziendistorsionsmodell (FDM) nach Stephan Typaldos
D.O. Die Typaldos-Methode," ed Bramsche, Germany: Rasch Druckerei,
2012.
[25] E. Nackaerts, G. Vervoort, E. Heremans, B. C. Smits-Engelsman, S. P.
Swinnen, and A. Nieuwboer, "Relearning of writing skills in Parkinson's
disease: a literature review on influential factors and optimal strategies,"
Neurosci Biobehav Rev, vol. 37, pp. 349-57, Mar 2013.
38

10. Appendix
10.1 Strength
strength hand flexion

5.5
R² = 0.6
strength (MRC)
5
R² = 0.75 a
4.5
b
4 Linear (a)
Linear (b)
3.5
1 2 3 4 5
measurements
Diagram 6: strength hand flexion
strength hand extension

6
strength (MRC)
5 R² = 0.75
a
R² = 0.75 b
4
Linear (a)
Linear (b)
3
1 2 3 4 5
measurements
Diagram 7: strength hand extension
39

strength supination
6
R² = 0.5
strength (MRC)
5
a
R² = 0.75
b
4
Linear (a)
Linear (b)
3
1 2 3 4 5
measurements
Diagram 8: strength supination
strength pronation
6
strength (MRC)
R² = 0
5
a
R² = 0.125 b
4
Linear (a)
Linear (b)
3
1 2 3 4 5
measurements
Diagram 9: strength pronation
strength elbow flexion

6
R² = 0
strength (MRC)
5
a
R² = 0.5 b
4
Linear (a)
Linear (b)
3
1 2 3 4 5
measurements
40

Diagram 10: strength elbow flexion
strength elbow extension

6 R² = 0.5
strength (MRC)
5
a
R² = 0.5
b
4
Linear (a)
Linear (b)
3
1 2 3 4 5
measurements
Diagram 11: strength elbow extension
hand-dynamometer
41
39 R² = 0.7
strength (kg)
37
a
35
R² = 0.00571 b
33
Linear (a)
31
Linear (b)
29
1 2 3 4 5
measurements
Diagram 12: hand-dynamometer
41

pinch-dynamometer
10
9.5
R² = 0.1
9
strength (kg)
8.5 a
8
7.5 b
7 R² = 0.455 Linear (a)
6.5
Linear (b)
6
1 2 3 4 5
measurements
Diagram 13: pinch-dynamometer
42

10.2 Range of motion
ROM hand flexion

90
85 R² = 0.83901
range of motion
80
75 a
70
R² = 0.94927 b
65
60 Linear (a)
55
Linear (b)
50
1 2 3 4 5
measurements
Diagram 14: ROM hand flexion
ROM hand extension

98
96 R² = 0.79412
range of motion
94
a
92
b
90 R² = 0.392
Linear (a)
88
Linear (b)
86
1 2 3 4 5
measurements
Diagram 15: ROM hand extension
43

ROM supination
92
90
range of motion
R² = 0.83112
88
86 a
84 b
82 R² = 0.71429 Linear (a)
80
Linear (b)
78
1 2 3 4 5
measurements
Diagram 16: ROM supination
ROM pronation
95
94
range of motion
93 R² = 0.57143
92 a
91 b
R² = 0.10526
90
Linear (a)
89
Linear (b)
88
1 2 3 4 5
measurements
Diagram 17: ROM pronation
ROM elbowflexion
141
140
range of motion
139
138
137 a
136 b
R² = 0
135
134 R² = 0.0232 Linear (a)
133
Linear (b)
132
1 2 3 4 5
measurements
44

Diagram 18: ROM elbow flexion
ROM elbow extension

11
R² = 0.5
10
range of motion
9
8 a
R² = 0.69565
7 b
6
Linear (a)
5
Linear (b)
4
1 2 3 4 5
measurements
Diagram 19: ROM elbow extension
45

10.3 MDS-UPDRS items
10.3.1 Rigidity MDS-UPDRS item 3.3
Rigidity is judged on slow passive movement of major joints with the patient in a re-
laxed position and the examiner manipulating the limbs and neck.
0: Normal: No rigidity.
1: Slight: Rigidity only detected with activation
maneuver.
2: Mild: Rigidity detected without the activation
maneuver, but full range of motion is
easily achieved.
3: Moderate: Rigidity detected without the activation
maneuver; full range of motion is
achieved with effort.
4: Severe Rigidity detected without the activation
maneuver and full range of motion not
achieved
Table 3: Rigidity MDS-UPDRS item 3.3
10.3.2 Finger Tapping MDS-UPDRS item 3.4
Each hand was tested separately. The physician demonstrated the task, but did not
continue to perform the task while the patient was being tested. The patient was in-
structed to tap the index finger on the thumb ten times as quickly AND as big as pos-
sible. Each side was rated separately, evaluating speed, amplitude, hesitations, halts
and decrementing amplitude.
0: Normal: No problems.
46

1: Slight: Any of the following: a) the regular
rhythm is broken with one or two inter-
ruptions or hesitations of the tapping
movement; b) slight slowing; c) the am-
plitude decrements near the end of the
10 taps.
2: Mild: Any of the following: a) 3 to 5 interrup-
tions during tapping; b) mild slowing; c)
the amplitude decrements midway in the
10-tap sequence.
3: Moderate: Any of the following: a) more than 5 in-
terruptions during tapping or at least one
longer arrest (freeze) in ongoing move-
ment; b) moderate slowing; c) the ampli-
tude decrements starting after the 1st
tap.
4: Severe: Cannot or can only barely perform the
task because of slowing, interruptions or
decrements.
Table 4: Finger Tapping MDS-UPDRS item 3.4
10.3.3 Pronation-supination movements of hands MDS-UPDRS item 3.6
Each hand was tested separately. The task was demonstrated, but not continued to
perform the task while the patient was being tested. The patient was instructed to
extend the arm out in front of his/her body with the palms down; then to turn the palm
47

up and down alternately ten times as fast and as fully as possible. Each side was
tested separately, evaluating speed, amplitude, hesitations, halts and decrementing
amplitude.
0: Normal: No problems.
1: Slight: Any of the following: a) the regular
rhythm is broken with one or two inter-
ruptions or hesitations of the movement;
b) slight slowing; c) the amplitude dec-
rements near the end of the sequence.
2: Mild: Any of the following: a) 3 to 5 interrup-
tions during the movements; b) mild
slowing; c) the amplitude decrements
midway in the sequence.
3: Moderate: Any of the following: a) more than 5 in-
terruptions during the movement or at
least one longer arrest (freeze) in ongo-
ing movement; b) moderate slowing c)
the amplitude decrements starting after
the 1st supination-pronation sequence.
4: Severe: Cannot or can only barely perform the
task because of slowing, interruptions or
decrements.
Table 5: Pronation-supination movements of hands MDS-UPDRS item 3.6
48

10.3.4 tremor MDS-UPDRS item 2.10
Over the past week, have you usually had shaking or tremor?
0: Normal: Not at all. I have no shaking or tremor.
1: Slight: Shaking or tremor occurs but does not
cause problems with any activities.
2: Mild: Shaking or tremor causes problems with
only a few activities.
3: Moderate: Shaking or tremor causes problems with
many of my daily activities.
4: Severe: Shaking or tremor causes problems with
most or all activities.
Table 6: Tremor MDS-UPDRS item 2.10
10.3.5 Kinetic tremor of the hands MDS-UPDRS item 3.16
This is tested by the finger-to-nose maneuver. With the arm starting from the out-
stretched position, have the patient perform at least three finger-to-nose maneuvers
with each hand reaching as far as possible to touch the examiner’s finger. The finger-
to-nose maneuver was performed slowly enough not to hide any tremor that could
occur with very fast arm movements. Repeated with the other hand, each hand was
rated separately. The highest amplitude was rated.
0: Normal: No tremor.
1: Slight: Tremor is present but less than 1 cm in
amplitude.
2: Mild: Tremor is at least 1 but less than 3 cm in
49

amplitude.
3: Moderate: Tremor is at least 3 but less than 10 cm
in amplitude.
4: Severe: Tremor is at least 10 cm in amplitude.
Table 7: Kinetic tremor of the hands MDS-UPDRS item 3.16
10.3.6 Hoehn and Yahr stage
0: Asymptomatic.
1: Unilateral involvement only.
2: Bilateral involvement without impairment of balance.
3: Mild to moderate involvement; some postural instability but physically independent;
needs assistance to recover from pull test.
4: Severe disability; still able to walk or stand unassisted.
5: Wheelchair bound or bedridden unless aided.
Table 8: Hoehn and Yahr stage
50

10.3.6 Letter of Content
51

The Effect of FDM On Micrographia in Parkinsonism

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

The Effect of FDM On Micrographia in Parkinsonism

Uploaded by

Copyright:

Available Formats

The effect of the Fascial Distortion Model

a single system study

Andreas Philipp Kacsir, dipl. PT BSc, MscPt, Msc Neurorehabilitationsforschung,

FDM-Therapeut (EFDMA), Fachdozent für Neurorehabilitation

Zentrum für Physiotherapie am Markt GmbH

fax. +41 71 722 81 82

3. ABSTRACT/KEY WORDS ...................................................................................... 8

4.2 Therapy approaches ............................................................................................................................... 11

4.3 The Fascial Distortion Model (FDM) ........................................................................................................ 12

4.4 Aim of the study ..................................................................................................................................... 12

5. MATERIALS AND METHODS .............................................................................. 13

5.1 Patient .................................................................................................................................................... 13

5.2 Assessments ........................................................................................................................................... 14

5.2.1 Handwriting task ................................................................................................................................. 14

5.2.2 Signature ............................................................................................................................................. 14

5.2.3 Motor status ........................................................................................................................................ 15

5.3.1 Procedure of the treatment ................................................................................................................. 15

5.4 Statistical Evaluation .............................................................................................................................. 16

6.1 General characteristics ........................................................................................................................... 17

6.1.1 Handwriting samples ........................................................................................................................... 21

6.1.1.1 Handwriting sample 1a ..................................................................................................................... 21

6.1.1.2 Handwriting sample 1b ..................................................................................................................... 21

6.1.1.3 Handwriting sample 2a ..................................................................................................................... 21

6.1.1.4 Handwriting sample 2b ..................................................................................................................... 22

6.1.1.5 Handwriting sample 3a ..................................................................................................................... 22

6.1.1.6 Handwriting sample 3b ..................................................................................................................... 22

6.1.1.7 Handwriting sample 4a ..................................................................................................................... 22

6.1.1.8 Handwriting sample 4b ..................................................................................................................... 23

6.1.1.9 Handwriting sample 5a (Follow up) ................................................................................................... 23

6.2 Measurement 1a and b ........................................................................................................................... 23

6.3 Measurement 2a and b ........................................................................................................................... 23

6.4 Measurement 3a and b ........................................................................................................................... 24

6.5 Measurement 4a and b ........................................................................................................................... 24

6.6 Measurement 5 (Follow-­‐up) ................................................................................................................... 25

6.7 Time for the handwriting task ................................................................................................................. 26

6.8 Mean letter height .................................................................................................................................. 26

6.9 Sentence length ...................................................................................................................................... 27

6.11 Signature .............................................................................................................................................. 28

8.1 Impact on clinical practice ...................................................................................................................... 33

8.2 Impact on future research ...................................................................................................................... 33

10.1 Strength ............................................................................................................................................... 39

10.2 Range of motion ................................................................................................................................... 43

10.3 MDS-­‐UPDRS items ................................................................................................................................ 46

10.3.1 Rigidity MDS-­‐UPDRS item 3.3 ............................................................................................................. 46

10.3.2 Finger Tapping MDS-­‐UPDRS item 3.4 ................................................................................................. 46

10.3.4 tremor MDS-­‐UPDRS item 2.10 ........................................................................................................... 49

10.3.6 Hoehn and Yahr stage ........................................................................................................................ 50

Table 1: Baseline characteristics ....................................................................................... 18

Table 2: Motor status ........................................................................................................... 19

Table 3: Rigidity MDS-UPDRS item 3.3 ........................................................................... 46

Table 4: Finger Tapping MDS-UPDRS item 3.4 .............................................................. 47

Table 5: Pronation-supination movements of hands MDS-UPDRS item 3.6 .............. 48

Table 6: Tremor MDS-UPDRS item 2.10 ......................................................................... 49

Table 8: Hoehn and Yahr stage ......................................................................................... 50

Diagram 1: time .................................................................................................................... 26

Diagram 2: mean letter height ............................................................................................ 26

Diagram 3: sentence length ................................................................................................ 27

Diagram 4: surface area ...................................................................................................... 27

Diagram 5: signature ........................................................................................................... 28

Diagram 6: strength hand flexion ....................................................................................... 39

Diagram 7: strength hand extension ................................................................................. 39

Diagram 8: strength supination .......................................................................................... 40

Diagram 9: strength pronation ............................................................................................ 40

6.6 Measurement 5 (Follow-‐up) ................................................................................................................... 25

10.3 MDS-‐UPDRS items ................................................................................................................................ 46

10.3.1 Rigidity MDS-‐UPDRS item 3.3 ............................................................................................................. 46

10.3.2 Finger Tapping MDS-‐UPDRS item 3.4 ................................................................................................. 46

10.3.4 tremor MDS-‐UPDRS item 2.10 ........................................................................................................... 49